Healthy Ageing: Opportunities and Challenges in Cornwall
Professor Raymond Tallis
27 November 2006

What a very great pleasure it is to be talking here this evening. I also feel very honoured and, considering the importance of the occasion and the eminence of previous lecturers, somewhat overawed. So thank you for your invitation to speak. A special thank you to Sir John for his introduction and to Keith Hambly-Staite who not only made the original contact but also engaged in a very helpful dialogue about the content of the lecture and, what is more, dug up some useful statistics about Cornwall that I have used in my talk.

I have been a lover of Cornwall for most of my life. Indeed, Cornwall has dug deep roots into the consciousness of myself and my family. I first visited it in 1955. It was our first post-war holiday and we stayed at the Port Minster Hotel at St. Ives I shall never forget our first sight of the sea as the Cornish Riviera Express rounded a corner and the unimaginably blue Carbis Bay was suddenly uncovered. I next came to Cornwall in 1970, before I took up my first job as a lowly House Officer. I was with Terry my wife-to-be, who is in the audience, and I remember spending hours simply staring at the sea. From 1980 onwards, we came to Cornwall with first one, and then two children, staying in Port Isaac and then Polzeath. Finally, in 2001, we bought a place in New Polzeath just a few minutes away from Pentireglaze and a pub – The Doom Bar - with the best view in the world.

Polzeath also goes a long way back in my imagination – to when I first read Enid Blyton. The opening paragraph of the first of the Famous Five books – Five on Treasure Island - refers to Polzeath. And I also associate Cornwall with Virginia Woolf. Indeed, my Cornwall of the mind is ‘Five Run Away to the Lighthouse’!

This part of the country, in short, has meant more to me and my family than pretty well anywhere else in the world. So it is nice to be able to say thank you in a more genial way than by buying a property and helping to put house prices out of the range of young Cornishmen and women trying to get on the housing ladder.

Well, to tonight’s theme. What I am going to offer you tonight is best described as ‘Evidence-based good cheer’ I am going to try to discredit the ‘miserabilism’ that assumes that the fact that people are living longer, means that things are bad and that they will get worse. In accordance with this view, the fact that I passed the age of 60 a month or so ago means that I am embarked on a road that will lead to my becoming an increasing burden or, more politely, ‘a challenge’. For Cornwall, with its own ageing population, which I will talk about presently, this means that health, social services and the community at large will face increasing burdens and increasing challenges.

The miserabilist view is captured in the final paragraph of Roy Porter’s masterly history of medicine:

Extending life becomes feasible but it may be a life exposed to degrading neglect as resources grow overstretched and politics turn men. What an ignominious destiny if the future of medicine turns into bestowing meagre increments of unenjoyed life. (1)

These are rather disturbing thoughts. Is this how things are going to be in the future – meagre increases of unenjoyed life expectancy? Will it simply mean more challenges and more burdens for the health and social services of Cornwall to deal with?

These are good questions. Every now and then it is useful for those of us involved in delivering medical care to step back and think about our ultimate aims.

Medicine, it seems to me, has two broad aims: to postpone dying due to disease; and to mitigate the suffering (pain, disability, anguish) it may bring. Despite the continuing remarkable triumphs of science-based medicine, some recent developments have prompted some commentators to question whether these two aims may be coming into conflict; whether this conflict is especially evident in the medicine of old age; and whether, in particular, increased life expectancy is inevitably associated with an increased burden of suffering due to illness.

In this lecture , I want to address this question, focussing on data mainly derived from the United Kingdom, though I believe that the (largely optimistic) conclusions that I draw will apply to Cornwall as much as to anywhere else.

The Demographic Revolution

First the good news: there is more chance of living to old age and life expectancy when you reach old age is increased. While we might not like the idea of getting old, it seems pretty attractive, as Woody Allen said, when you think of the alternative: dying young.

The century just past has witnessed a remarkable extension of life worldwide. The most striking changes have occurred in developed countries. In the United Kingdom, for example, life expectancy at birth increased by nearly a decade in both men and women between the late 1940s, and the mid-1990s. Life expectancy in males increased from 66 to 74.4 and in females from 70.5 to 79.6 (2). Life expectancy increases over the entire century were even more dramatic: a male born in 1900 had an average life expectancy of 45 years and a female 49; by 2000, these figures had increased to 76 and 81 respectively. (3) In the earlier half of the 20th century, decline in infant mortality was the most important determinant of increased life expectancy at birth. At the end of the 20th century decrease in mortality at late ages had become most important.

These trends continue. According to a Report by the House of Lords Science and Technology Committee, life expectancy in the UK is increasing at a rate of about 2 years for each decade that passes. (4) Oeppen and Vaupel have estimated that, in those countries which are most demographically advanced, life expectancy is increasing at about three months each year. If these trends continue, life expectancy in women will reach 100 in at least one country by 2060. (5)

If we focus on the life expectancy of people who have already reached later life, as opposed to overall life expectancy, the figures are almost as dramatic. Life expectancy in the United Kingdom in men and women aged 60 increased between 1980 and 2000 from 16.3 to 19.5 and from 20.8 to 23.0 years respectively. (6) A recent study of men with private pensions showed that their life expectancy at 65 had increased from 83 years and 2 months in 1997 to 86 years and 7 months in 2005. The figure for 2015 is anticipated to be just under 90. (7) Mortality rates are slowing down in extreme old age and tending to a ceiling. (8)

The result of this of this has been a change in the age structure of the population. In the first fifty years of the NHS, while the overall population of England and Wales increased by 20% and pre-school children by 9%, the over 80s increased by 240%. 2 A similar disproportionate increase in older people has been seen in Cornwall. Between 1991 and 2006, the overall population increased by 9.8% while the figure for the over 65 population was 13.4% (9)

Concerns About the Ageing of the Population

All of this must surely be very good news. There could be no greater triumph of medicine, public health and social policy than that it should result in more people living to a ripe old age. This is above all what we want for ourselves and our loved ones. The figures I have given you should surely, therefore, be occasion for unalloyed delight. However, many have expressed concerns about the impact of an ageing population in which a greater portion of people achieve old age and live on longer when they are old. The prediction of demographic trends in Cornwall between 2006 and 2028 have been described by a very senior source as ‘scary’. During this time, the population 65 and over will increase by 71,000 and the proportion of the population over 65 will increase from 20% to 28.5% - one of the highest in England. The number of people over 85 will increase by 117%. (10)

The basis for these concerns may be summarised by Roy Porter’s observation that, at a time when death from acute illness has been replaced by death from chronic illness, ‘longer life means more time to be ill’. 2 Is this true?

One might expect it would be. There is, after all, an exponential relationship between age and the prevalence of chronic ill health and this is in part due to the exponential relationship between age and chronic disabling diseases, particularly neurological diseases such as Parkinson’s disease, Alzheimer’s disease and stroke. The chances of being disabled from a stroke increase nearly a hundred fold between the ages of 45 and 85. (11) And non-neurological disabling diseases such as osteoarthritis have a similar exponential relationship to age.

These concerns seemed to be born out by study carried out in the United Kingdom in the 1980’s which showed that the prevalence of disability in the population rose exponentially with age. (12) This applied to every level of disability from minor problems to being totally dependent on others. A study carried out in the later 1980s also found that there was a very steep rise in dependency on others for activities of daily living as one moved from ‘young old age’ to ‘old old age’. For example, the proportion of people depending on others for shopping rose from less than 10% in people in their late 60s to over 70% in people over 85. (13)

Are things working out as badly as people fear?

Roy Porter’s observation, which we have just quoted, that living longer means more time to be ill is certainly true. The question we have to ask ourselves, however, is whether in practice people are living with illness for a longer time; whether more time to be ill means spending more time actually ill.

We may imagine four possible scenarios associated with increased life expectancy:

The figures for the UK showing the trends over the last 20 years indicate that the ratio of healthy life expectancy to overall life expectancy has not decreased, despite substantial increases in life expectancy. (14) The extra years of life are not simply extra years of ill health. If you look over the same 20 year period at the life expectancy and healthy life expectancy of women over 65 the latter has increased proportionately slightly more (20%) compared with overall life expectancy (17%). (14)

The very large databases examined by Manton and others in USA have shown a similar not discouraging picture. Whereas between 1962 and 1976 life expectancy increased by 1.8 years only 0.3 years of which were without activity restriction (15), the more recent data are much less worrying. According to the National Long Term Care survey, between 1982 and 1999 disability rates in people over 65 have decreased from 26.2% to 19.7%. (16) This is a 2% decrease per year, double the decrease in the mortality rate, and it is accelerating. In Denmark, a study conducted over the last decade has shown a compression of morbidity, with the period of chronic illness before death showing a slight reduction. (17)

One of the most remarkable observations is that the duration of one’s life has little impact on the time one spends in hospital. Richard Himsworth found that those who died in their nineties spent very little more time in hospital in the 15 years before death than those who died in their seventies. (18) The extra 20 years of life was not an extra twenty years spent in hospital. A more recent study (19) has found that people who die below the age of 45 do not spend more time in hospital in the three years before death than those who die above 45.

Why are the trends not so worrying as might have been expected? In part this is due to improvements in the prevention and treatment of illnesses that cause chronic disability. A good example here is stroke, the commonest cause of severe disability in later life. Two studies in Oxford UK – the Oxford Community Stroke Project 11 and the OXVASC study (20) – separated by 20 years examined the same population. In both cases, they found an exponential relationship between the incidence of stroke and age. In the later study, however, the age-related incidence had fallen dramatically. The result was that, instead of the anticipated increase of about 30% in total strokes (due to the ageing of the populations studied), there was an approximately 30% fall. This is an important observation, because our predictions for the future – in particular future demands on health and social services – will be very sensitive to trends in disability and ill health.

Will Ageing Come to the Rescue?

We cannot, of course, postpone chronic illness for ever. Surely, therefore, we should expect the demographic trends to result in an elderly population with an increasing burden of illness because postponed illnesses eventually arrive? In order to understand the surprising and rather cheerful answer to this question, we need to remember something else that is going one as people get older: biological ageing

Ageing has been described by Kirkwood as ‘an harmonious decline of all organ systems leading to increased probability of death.’ (21) There are two points to take away from this definition. The first is that the decline is harmonious : it is generalised and not associated with events localised to particular organs. It will not therefore be accompanied by symptoms such as pain, nausea, dyspnoea and so on. Secondly, it is nonetheless associated with an increase in mortality. The reasons for this are best captured by thinking of the biologically ageing body having globally impaired mechanisms for resisting challenges from infection or trauma or other assaults from accident or disease. The ageing body is less able to adapt to challenges of various sorts and so is more likely to succumb to a challenge that would leave a younger body diminished but viable.

This presents a possible scenario which has been beautifully captured by Professor John Grimley Evans:

By delaying the onset of disabling diseases to later ages when intrinsic ageing has raised fatality by reducing adaptability, the average duration of disability before death will be shortened. In brief, we will spend a longer time living and a shorter time dying. (italics mine) (22)

That this scenario is a genuine possibility is shown by data analysed by Grimley Evans. He found that the period of dependent life before death in a particular population decreased slightly in males dying in their late 80s compared with those dying in their 60s. In females, the findings were even more encouraging: dependent life before death fell from just under 9 years for women dying in their 60s and to just under 5 years for women dying in their late 80s. (22)

We might conclude from this that the older the age attained before becoming disabled, the shorter period of dependency before death. This is illustrated by a recent study of survival in stroke. (23) There was a dramatically lower survival rate in patients who acquired their strokes over 85 compared with those who acquired them below 85. The bottom line is that postponement of disabling diseases leads not merely to postponement but to reduction and prevention of lifetime disability.

Realising the Potential for a Healthy Old Age

The key to a healthy old age and to an increased life span that is not associated with an increased, and protracted, burden of illness must lie in the postponement of disability. There are many possible strategies and I have space to mention only a few here.

First we should pay more attention to the promotion of a healthy lifestyle (exercise, weight control, healthy diet, avoiding smoking and excess alcohol, and so on). Education in childhood, and throughout adult life, is essential here. Secondly, there should more focus on the preventing the preventable, as in for example preventing strokes. For a long time, epidemiologists have talked about the so-called ‘Rules of Halves’: half of the people with a treatable risk factor are not detected; half of those detected are not treated; and half of those treated do not reach the target value to maximise protection. This rule has certainly applied in the UK until recently, as a study of the use of cholesterol-lowering drugs for secondary prevention in patients with known coronary heart disease has shown. The new contract for family doctors places a great emphasis on prevention and there is much well-founded optimism that this will deliver a reduction in cardiovascular disease. There is, however, a long way to go.

The benefits of health promotion and preventive medicine have been dramatically illustrated in a recent paper published in Journal of the American Medical Association (24) which looked at the influence of risk factors such as being overweight, having high blood pressure, high blood sugar, exercise, smoking, alcohol intake, on long time survival and health. This was a forty year follow up study. It found that middle aged men who had no risk factors had a 69% chance of surviving to be over 85 and, more importantly, to surviving to over 85 in good health. By contrast, those who had six or more risk factors had only 22% chance of survival to 85 and only a 9% chance of survival to 85 in good health.

In this regard, it is interesting to note that smoking accounts for more than half of the difference in life expectancy and healthy life expectancy between rich and poor. (25)

Another area where there are huge opportunities for prevention of chronic illness in old age is in the better use of technologies we have already, most notably drug treatments. In the 80s and 90s a series of studies showed that many elderly people were on suboptimal drug treatment – inadequate or untailored doses – or on inappropriate treatment. One study showed that 10% of elderly people admitted acutely to hospital were on contra-indicated drugs. (26) Another study found that about 6% of acute admissions of elderly people were due to adverse drug reactions arising out of inappropriate medication. (27) This was confirmed in a more recent survey (28) which found that 6.5 % of 18,000 acute admissions were due to adverse drug reactions, of which about two thirds were avoidable. The median age of patients admitted due to adverse drug reactions was 76 years.

Finally, in the case of those patients who do become disabled, we would be able to mitigate its impact better than we do now by more universal application of best care. In the case of neurological disability, there are very exciting prospects for reversing or limiting the underlying neurological damage by applying what we already know about plasticity in the nervous system and the drivers to recovery. (29)

In short, there is no reason why we should not expect that, with better medical care, the period of disability before death will be further greatly reduced.

Fiscal Panic

Even those who are persuaded of the possibility of the optimistic scenario I have just described may still worry whether it is affordable. There are two kind of fiscal panics. The first panic relates to the cost of ensuring that people arrive at old age in good health and that they remain in good health for the greater part of the remainder of their life.

There will of course be some additional costs, arising out of the availability of new treatments that will be particularly relevant to medical problems of old age, and the appropriate expectation that older people will have access to them. Against this, however, is the fact that age specific need for health care is falling. (Older people will always require a lion’s share of health care because expenditure will always be maximal in the last year of life, irrespective of the age at which one dies.) Encouragingly, however, there has been smaller increase in per capita costs for older ages compared with younger age groups. Even more remarkably, per capita costs of hospital and community services for people over 85 decreased in real terms in the UK between the mid-eighties and the mid-nineties – supporting the prediction that, although there are more 85 year olds, they are in better health. (31)

The other panic arises from the assumption that the nation cannot afford an increasing population of old people even if they are healthy. This must be challenged. It is based upon the assumption that old people cannot be net contributors to the economy, or contribute to meeting the wide needs of society. Older people can be producers as well as consumers of goods and services – for example formal and informal caring. We can solve the pension’s crisis, as was acknowledge by the Turner report, by encouraging people to save longer and harder and to work longer. New work patterns will emerge. Working longer – for example relating the typical age of retirement to the median age of death – is not a bad price to pay for living longer. After all, work allows evenings and weekends off; such perks are not available in death. The general message is this: many of the problems of ‘the elderly population’ are social rather than biological in origin and are therefore amenable to being solved or ameliorated by changing social attitudes.

There are, of course, some special problems in Cornwall in realising the dream of a long and healthy old age for most people. As my audience is more knowledgeable than me on this, I will make only a few comments. There is the geographical challenge of meeting the needs of a scattered population and the extra costs that come from reaching out to small groups of people. There are the travel problems within the county, exacerbated by tourism in the high season. There is also the fact that Cornwall has a low GDP per head – 75% of the EU average. (32) Set against this, however, is the rapid rise of GDP per head – better than the national picture and faster in the last few years than in the late 90s. There is also the problem, by no means unique to Cornwall, of the costs of endless reorganisation of health and community services which has plagued anyone trying to improve care for older people for two decades. (33)

There are also some special strengths. There is a clear strategy linked to the main threats to health in old age. 33. There is the brand new medical school with a mission to make an impact locally as well as in the wider world. There is a potential increasing input of volunteers including from incoming retirees. Obesity levels are below the national average! And, above all, there is the quality of the people themselves, with traditions of self-reliance that reflect the traditions of a region where farming and fishing have been so important.

Conclusion

In summary, I believe that a long and healthy life for most Cornish people lies within its grasp. It is certainly not a biological or economic impossibility. We may imagine a future in which the health span increasingly approximates to a long life span: postponement of the onset of chronic and disabling disease; abatement of the progression of severity of disease; and lesser postponement of death. To put this another way, we may imagine a future in which Cornishmen and Cornishwomen ‘Bop till they drop’.

Raymond Tallis FRCP FMedSci DLitt LittD
Emeritus Professor of Geriatric Medicine
University of Manchester

Address for correspondence: raymond@rtallis.wanadoo.co.uk

Acknowledgements I am enormously grateful for being invited to give this talk and for the support of the Cornwall Lecture team. I am particularly indebted to Keith Hambly-Staite for his guidance, his support and for furnishing me with the data on Cornwall.